Tobacco and alcohol use; suicide ideation, plan, and attempt among adolescents; and the role of legal purchase age restrictions: a pooled population-based analysis from 58 countries

Abstract

Background: We aimed to evaluate the potential independent and interactive associations of tobacco and alcohol use with suicide ideation, plan, and attempt among adolescents, and the role of legal purchase age restrictions among these associations.

Methods: A pooled cross-sectional analysis was conducted with data from the Global School-based Student Health Survey (GSHS) (2013-2019), the US Youth Risk Behavior Surveillance System (YRBSS) (2021), and a Chinese school-based health survey (2017). Self-reported use of tobacco and alcohol during the past 30 days, and suicide ideation, plan, and attempt during the past year, were collected from questionnaires. Country-level purchase age restrictions on tobacco and alcohol products were obtained from official government websites.

Results: Among the 211,022 adolescents from 58 countries, 46.7% were boys. Compared with adolescents who used neither tobacco nor alcohol, those who used both tobacco and alcohol had the highest odds of suicide ideation (boys: 2.42 [95% CI: 2.25-2.61]; girls: 3.19 [95% CI: 2.98-3.40]; P _difference < 0.001), suicide plan (boys: 2.39 [95% CI: 2.21-2.58]; girls: 3.33 [95% CI: 3.11-3.57]; P _difference < 0.001), and suicide attempt (boys: 3.24 [95% CI: 3.00-3.51]; girls: 4.03 [95% CI: 3.75-4.33]; P _difference < 0.001). In countries with higher suicide plan prevalence, boys who use tobacco and who live in countries with tobacco purchase age restrictions had lower odds of suicide plan (1.86 [95% CI: 1.64-2.12]) than those who lived in countries without restrictions (2.81 [95% CI: 2.32-3.42]). Similarly, girls who use tobacco and who live in countries with legal age purchase restrictions displayed lower odds of suicide plan (2.20 [95% CI: 1.98-2.45]) compared to those who live in countries without restrictions (4.61 [95% CI: 3.65-5.83]). However, our study revealed no subgroup differences in whether countries have legal tobacco or alcohol purchase age restrictions in association with suicide ideation, plan, and attempt risk in countries with a lower prevalence of suicide behaviors.

Conclusions: Tobacco and alcohol consumption are strongly associated with the risk of suicide behaviors among adolescents, particularly among girls. Country-level tobacco control strategies may have the potential to reduce risks of suicide behaviors associated with tobacco use among adolescents.

Keywords: Adolescent health; Alcohol use; Global health; Health policy; Suicide behavior; Tobacco use.

Fig. 1

Diagram of participant inclusion process for analysis

Fig. 2

Associations of tobacco and alcohol use with suicide ideation, plan, and attempt among adolescents in 58 countries, by sex, age of purchase restrictions, and the prevalence of suicide behaviors. Note: models were adjusted for age, body mass index, insufficient physical activity (yes/no), long sedentary behavior (yes/no), survey weight, SDI, feeling lonely during the past 12 months (yes/no), and feeling worried during the past 12 months (yes/no). P1 for difference indicates to differences of suicide ideation, plan, and attempt in tobacco use (or alcohol use) from countries with or without legal purchase age restrictions in countries with lower prevalence of suicide ideation, plan, and attempt; P2 for difference indicates to differences of suicide ideation, plan, and attempt in tobacco use (or alcohol use) from countries with or without legal purchase age restrictions in countries with higher prevalence of suicide ideation, plan, and attempt. Lower group refers to below the country-level prevalence of suicide ideation, plan, and attempt, respectively; higher group refers to above the country-level prevalence of suicide ideation, plan, and attempt, respectively. In A, there were no “No tobacco use and no purchase age restrictions” and “Only tobacco use” among the lower group